Provider Demographics
NPI:1669709507
Name:WORTHAM, MARNIE D (LOT)
Entity type:Individual
Prefix:MS
First Name:MARNIE
Middle Name:D
Last Name:WORTHAM
Suffix:
Gender:F
Credentials:LOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60580
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79711-0580
Mailing Address - Country:US
Mailing Address - Phone:432-563-2380
Mailing Address - Fax:432-561-4377
Practice Address - Street 1:2811 LAFORCE BLVD
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79711-0580
Practice Address - Country:US
Practice Address - Phone:432-563-2380
Practice Address - Fax:432-561-4377
Is Sole Proprietor?:No
Enumeration Date:2009-11-13
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110047225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist